Tailored re-roofing technique for pulsatile tinnitus caused by sigmoid sinus dehiscence or diverticulum.

Background: Sigmoid sinus diverticulum/dehiscence (SSD) is one of the treatable causes of venous pulsatile tinnitus. It can be diagnosed using temporal bone computed tomography (CT) or magnetic resonance angiography/venography (MRA). In cases where patients find their symptoms intolerable, surgical treatment is typically preferred. Here, we have presented a novel surgical technique involving sigmoid sinus re-roofing and have analyzed its feasibility. Methods: Between January 2020 and July 2023, approximately 150 patients with pulsatile tinnitus were evaluated at two different tertiary hospitals. Of these, 12 patients were diagnosed with SSD, and seven underwent surgical treatment. Five patients were treated with tailored reroofing (TRR) of the sigmoid sinus and two with transmastoid resurfacing (MRS) of the sigmoid sinus. We compared the Korean tinnitus handicap inventory (K-THI) score, pure tone audiogram (PTA) threshold, and CT findings before and a month after surgeries for these two techniques. The operation time was also analyzed. Results: In TRR cases, the K-THI score reduced from 55.0 ± 31.4 preoperatively to 4.0 ± 3.0 postoperatively, and the SSD was well-repositioned and covered by a bone chip postoperatively. In MRS cases, the K-THI score reduced from 41.0 ± 9.9 preoperatively to 15.0 ± 21.2 postoperatively, and the SSD was well-covered with bone cement postoperatively. The average surgical time of five TRR and two MRS cases were 77.5 ± 32.5 and 174.0 ± 75.0 min, respectively. No complications were noted. Conclusions: Despite the insufficient number of cases, we noted that TRR requires a reasonable amount of time, involves a smaller incision, and may provide favorable outcomes compared to conventional MRS in cases of pulsatile tinnitus associated with SSD. Level of evidence: IV.

Differential Biases and Variabilities of Deep Learning-Based Artificial Intelligence and Human Experts in Clinical Diagnosis: Retrospective Cohort and Survey Study.

BACKGROUND: Deep learning (DL)-based artificial intelligence may have different diagnostic characteristics than human experts in medical diagnosis. As a data-driven knowledge system, heterogeneous population incidence in the clinical world is considered to cause more bias to DL than clinicians. Conversely, by experiencing limited numbers of cases, human experts may exhibit large interindividual variability. Thus, understanding how the 2 groups classify given data differently is an essential step for the cooperative usage of DL in clinical application. OBJECTIVE: This study aimed to evaluate and compare the differential effects of clinical experience in otoendoscopic image diagnosis in both computers and physicians exemplified by the class imbalance problem and guide clinicians when utilizing decision support systems. METHODS: We used digital otoendoscopic images of patients who visited the outpatient clinic in the Department of Otorhinolaryngology at Severance Hospital, Seoul, South Korea, from January 2013 to June 2019, for a total of 22,707 otoendoscopic images. We excluded similar images, and 7500 otoendoscopic images were selected for labeling. We built a DL-based image classification model to classify the given image into 6 disease categories. Two test sets of 300 images were populated: balanced and imbalanced test sets. We included 14 clinicians (otolaryngologists and nonotolaryngology specialists including general practitioners) and 13 DL-based models. We used accuracy (overall and per-class) and kappa statistics to compare the results of individual physicians and the ML models. RESULTS: Our ML models had consistently high accuracies (balanced test set: mean 77.14%, SD 1.83%; imbalanced test set: mean 82.03%, SD 3.06%), equivalent to those of otolaryngologists (balanced: mean 71.17%, SD 3.37%; imbalanced: mean 72.84%, SD 6.41%) and far better than those of nonotolaryngologists (balanced: mean 45.63%, SD 7.89%; imbalanced: mean 44.08%, SD 15.83%). However, ML models suffered from class imbalance problems (balanced test set: mean 77.14%, SD 1.83%; imbalanced test set: mean 82.03%, SD 3.06%). This was mitigated by data augmentation, particularly for low incidence classes, but rare disease classes still had low per-class accuracies. Human physicians, despite being less affected by prevalence, showed high interphysician variability (ML models: kappa=0.83, SD 0.02; otolaryngologists: kappa=0.60, SD 0.07). CONCLUSIONS: Even though ML models deliver excellent performance in classifying ear disease, physicians and ML models have their own strengths. ML models have consistent and high accuracy while considering only the given image and show bias toward prevalence, whereas human physicians have varying performance but do not show bias toward prevalence and may also consider extra information that is not images. To deliver the best patient care in the shortage of otolaryngologists, our ML model can serve a cooperative role for clinicians with diverse expertise, as long as it is kept in mind that models consider only images and could be biased toward prevalent diseases even after data augmentation.

Simultaneous Nonmastoidectomy Infrapromontorial Tumor Removal and Cochlear Implantation in Vestibular Schwannoma Patient.

INTRODUCTION: Restoration of hearing in patients with vestibular schwannoma (VS) and poor hearing poses a great challenge. Simultaneous cochlear implantation during surgery for VS removal offers favorable hearing outcome if the cochlear nerve remains intact. Recent refinement of surgical techniques using the endoscope has made it possible to simultaneously restore the hearing and remove the tumor. CASE DESCRIPTION: A 62-year-old male had left severe sensorineural hearing loss and a 4 mm intracanalicular VS. We performed simultaneous nonmastoidectomy infrapromontorial VS removal and cochlear implantation in this patient to achieve minimal invasiveness and to provide maximal hearing restoration. The tumor was removed via this corridor while maintaining the integrity of cochlear as well as facial nerves with full insertion of a medium length cochlear implant electrode. After surgery, the patient showed good hearing rehabilitation. CONCLUSION: Simultaneous infrapromontorial VS removal and nonmastoidectomy cochlear implantation serves as an option for hearing restoration with minimal invasiveness in small VS removal.

One-stage cochlear implantation in patients with chronic otitis media using canal wall up mastoidectomy.

BACKGROUND: Cochlear implantation (CI) with subtotal petrosectomy was recommended to avoid the complications for patients with chronic otitis media (COM). OBJECTIVES: To evaluate the surgical outcomes of CI in patients with COM using a one-stage operation with canal wall up mastoidectomy (CWUM). METHODS: Thirty-five patients with COM who underwent CI with CWUM as a one-stage between 2009 and 2017 were participated. They divided into those with inactive COM and active COM. The anatomical success rate, postoperative complication, and hearing outcomes were analyzed. RESULTS: Twenty-four patients had inactive COM and seven with active COM. Three of the 31 patients (9.7%) had otorrhea from the ear undergone surgery. Two of these three patients had myringitis after CI and their symptoms improved after conservative management. Although infection of the tympanic membrane in the third patient was controlled after conservative management, a perforation was left. Postoperative otorrhea occurred in two patients (8.3%) in the inactive COM group and one patient (14.3%) in the active COM group. CONCLUSION: This study indicates that infection control and successful implantation can be achieved through a one-stage CI operation with CWUM in selected patients with COM.HIGHLIGHTSAlthough COM was once considered a contraindication to CI, CI in patients with COM has been made feasible by STP before CI or simultaneously with CI.Simultaneous CI with CWUM was performed for 31 patients with COM.Three patients (9.7%) had minor complications after the surgery and only one patient experienced device explantation which was due to device failure.

Comparison of Clinical Characteristics and Surgical Outcomes of Cystic and Solid Vestibular Schwannomas.

OBJECTIVE: The aim of this study was to compare the clinical characteristics of cystic vestibular schwannomas (CVSs) and solid vestibular schwannomas (SVSs). STUDY DESIGN: Retrospective review. SETTING: Tertiary care center. PATIENTS: A total of 220 patients who underwent microsurgery for vestibular schwannomas between 2007 and 2016. INTERVENTION: CVSs were defined as cystic components ≥1/3 of total tumor volume based on automated volume measurement. Tumors larger than 5 cm were defined as large tumors. MAIN OUTCOME MEASURES: Clinical characteristics and surgical outcomes, including preoperative symptoms, hearing threshold, vestibular function, tumor volume, extent of resection, facial nerve outcomes, and nonfacial complications were evaluated. RESULTS: Tumor volume was significantly larger in CVSs (20.44 ±â€Š13.85 cm in CVSs; 4.75 ±â€Š6.48 cm in SVSs, p < 0.001) and the proportion of larger tumors was also greater in CVSs (66.0% in CVSs; 11.4% in SVSs, p < 0.001). Preoperative dizziness was highly prevalent in CVSs (32.1% in CVSs; 18.6% in SVSs, p = 0.038) and postoperative facial nerve outcomes were significantly worse in CVSs (67.9% favorable rate in CVSs; 87.4% favorable rate in SVSs, p = 0.001). When the comparison was limited to large tumors, no clinical characteristics or surgical outcomes were significantly different. Tumor volume had a greater effect than tumor type on the surgical outcomes. The odds ratios for subtotal resection and unfavorable facial nerve function with a large tumor were 5.77 (confidence interval [CI]: 1.52-21.95, p = 0.010) and 5.34 (CI: 1.41-20.22, p = 0.014), respectively. CONCLUSION: CVSs tend to be larger than SVSs. Tumor volume, not cystic component, is thought to be a major determinant of surgical outcomes.